# Trauma-Informed Care in Family Medicine

## Introduction

Trauma exposure is remarkably common, with over 60% of adults reporting at least one adverse childhood experience (ACE). The effects of trauma extend far beyond mental health, influencing chronic disease risk, health behaviors, and patient engagement with the healthcare system. Trauma-informed care (TIC) is a framework that shifts the clinical question from "What is wrong with you?" to "What happened to you?"

## Defining Trauma

Trauma results from an event, series of events, or set of circumstances experienced as physically or emotionally harmful or threatening, with lasting adverse effects on functioning. Acute trauma refers to a single incident such as an assault, accident, or natural disaster. Chronic trauma involves repeated, prolonged exposure such as domestic violence, child abuse, or war. Complex trauma involves multiple, varied traumatic events, often interpersonal and beginning in childhood. Historical and intergenerational trauma refers to collective trauma affecting communities across generations, such as colonization, slavery, and genocide.

## Adverse Childhood Experiences (ACEs)

### The ACE Study

The landmark CDC-Kaiser Permanente study of over 17,000 adults linked childhood adversity to adult health outcomes. The study identified ten categories of ACEs: physical, emotional, and sexual abuse; physical and emotional neglect; and household dysfunction (including domestic violence, substance abuse, mental illness, incarceration, and parental separation). A dose-response relationship was established, with higher ACE scores correlating with increased risk of chronic disease, mental illness, and early death.

### Health Impacts by ACE Score

An ACE score of 4 or more is associated with a 2-fold risk of ischemic heart disease, a 4-fold risk of depression, a 12-fold risk of suicide attempt, a 7-fold risk of alcohol use disorder, and a reduction in life expectancy by approximately 20 years.

![ACE pyramid showing the relationship between adverse childhood experiences and health outcomes across the lifespan](ace-pyramid-diagram.jpg)

## Principles of Trauma-Informed Care

SAMHSA identifies six key principles of trauma-informed care.

### 1. Safety

A physically and emotionally safe clinical environment should be created through calm, predictable interactions, privacy during sensitive conversations, and minimizing environmental triggers such as loud noises and crowded waiting rooms.

### 2. Trustworthiness and Transparency

Procedures should be explained before performing them. Commitments should be followed through, and consistency maintained. Clear information about treatment plans and next steps should be provided.

### 3. Peer Support

Patients should be connected with peer support groups and community resources. Peer navigators can facilitate engagement for patients with complex trauma histories.

### 4. Collaboration and Mutuality

Power should be shared in the clinical encounter through shared decision-making. The patient should be recognized as the expert on their own experience and involved in treatment planning.

### 5. Empowerment, Voice, and Choice

Patient autonomy and self-efficacy should be prioritized. Choices should be offered whenever possible regarding exam positioning, timing of procedures, and who is present during an exam. Building on patient strengths rather than focusing solely on deficits is essential.

### 6. Cultural, Historical, and Gender Issues

The intersection of trauma with race, ethnicity, gender identity, sexual orientation, and socioeconomic status should be recognized. Implicit biases and structural inequities within the healthcare system should be addressed, and culturally responsive care should be provided.

## Implementing TIC in the Clinical Encounter

### Communication Strategies

Universal precautions should be used, assuming any patient may have a trauma history. Permission should be asked before discussing sensitive topics or performing physical examinations. Open-ended, nonjudgmental language should be used, and emotional responses should be normalized with statements such as "Many people who have experienced similar things have felt this way." Tone, pace, and body language should be monitored.

### Screening for Trauma

The ACE questionnaire can be used in clinical settings, though routine screening remains debated. Current trauma exposure should be screened for, including intimate partner violence (using HITS or HARK tools) and human trafficking. The Primary Care PTSD Screen (PC-PTSD-5) is a five-item screen for PTSD symptoms. If screening is implemented, adequate resources for referral and follow-up must be ensured.

### Trauma-Sensitive Physical Examination

Each step of the exam should be explained before and during the procedure. Patient control should be offered with statements such as "You can ask me to stop at any time." Draping that maximizes dignity should be used. A chaperone should be provided, with the patient choosing. Pelvic and rectal exams may be particularly triggering and should proceed with extra sensitivity.

![Trauma-informed clinical encounter checklist for primary care visits](tic-clinical-checklist.jpg)

## Recognizing Trauma-Related Presentations

### Behavioral Indicators

Behavioral indicators include frequent missed appointments or late cancellations, avoidance of specific procedures or examinations, hypervigilance or exaggerated startle response in the clinic, difficulty trusting providers or forming a therapeutic alliance, and self-destructive behaviors such as cutting, substance use, or risky sexual behavior.

### Somatic Presentations

Somatic presentations include chronic pain syndromes (fibromyalgia, chronic pelvic pain, irritable bowel syndrome), medically unexplained symptoms, frequent emergency department visits, and functional neurological symptoms.

### Psychiatric Comorbidities

Psychiatric comorbidities include PTSD, complex PTSD, depression, anxiety disorders, substance use disorders, dissociative disorders, and borderline personality disorder.

## Treatment Considerations

### In the Primary Care Setting

A consistent therapeutic relationship should be built over time. Modifiable health behaviors should be addressed with motivational interviewing. Comorbid conditions including depression, anxiety, insomnia, and chronic pain should be treated. Sertraline and paroxetine are FDA-approved for PTSD. Prazosin is used for trauma-related nightmares, though evidence is mixed.

### Referral for Specialized Treatment

Trauma-focused CBT is evidence-based for PTSD in adults and children. EMDR (Eye Movement Desensitization and Reprocessing) is a first-line therapy for PTSD. Prolonged Exposure Therapy involves systematic confrontation of avoided trauma-related stimuli. Somatic Experiencing and other body-based therapies are additional options.

## Clinician Well-Being

Caring for trauma-exposed patients places clinicians at risk for secondary traumatic stress, vicarious trauma, and burnout. Protective strategies include regular supervision, peer support, maintaining work-life boundaries, and personal self-care. Organizations should create cultures that support clinician well-being alongside patient-centered care.

![Organizational framework for implementing trauma-informed care across the practice](tic-organizational-framework.jpg)

## Clinical Pearls

Trauma-informed care is not about eliciting trauma narratives; it is about creating conditions of safety and trust in every encounter. Universal precautions work better than selective screening because many patients do not disclose trauma even when directly asked. Chronic pain, functional syndromes, and high healthcare utilization may be expressions of unresolved trauma. A trauma-informed approach improves patient engagement, satisfaction, and health outcomes while reducing no-show rates. Clinician self-awareness of personal trauma history and emotional reactions is essential to providing effective TIC.

## References

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the ACE study. *Am J Prev Med*. 1998;14(4):245-258.
2. SAMHSA. *SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach*. HHS Publication No. (SMA) 14-4884. 2014.
3. Machtinger EL, Cuca YP, Khanna N, et al. From treatment to healing: the promise of trauma-informed primary care. *Womens Health Issues*. 2015;25(5):474-482.
4. Prins A, Bovin MJ, Smolenski DJ, et al. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): development and evaluation within a veteran primary care sample. *J Gen Intern Med*. 2016;31(10):1206-1211.